Several inmates from the same housing unit have come to nursing sick call with complaints of feeling generally unwell, blurred vision, and some difficulty breathing. Since they are all from the same unit an infectious condition is considered. This is flu season so it could be the flu virus….but maybe something else?

Ours is a clever patient population. When confined in a secure setting with little in the way of resources, they are able to manufacture a wide array of items for personal use or barter on the prison underground market.

Homemade alcohol is one such commodity and is fairly common in the US prison system. Local names for prison alcohol products include hooch, pruno, juice, buck, chalk, brew, raisin jack, and jump. The brew is most often made from fermented fruit but any food source will work.

The Centers for Disease Control (CDC) reported on five outbreaks of deadly botulism from prison hooch in the Arizona, California, and Utah prison systems. Although the botulism bacteria can be introduced through any fresh food item, potato peels were identified as the source in several of the CDC investigated outbreaks. Botulism is caused by a toxin produced when a bacteria commonly found in soil is placed in an oxygen-deprived environment – like the closed containers used for DIY alcohol production. The toxin is produced during the fermentation process if no heat is applied to kill the bacteria.

Signs that Trouble is Brewing

Correctional nurses must be aware of the symptoms for botulism if their patients have a propensity to create their own moonshine.

It is important to act on early signs of botulism as the nerve paralysis caused by the bacterial toxin can quickly move to the respiratory muscles and lead to death. Often the first signs involve the eyes with double vision, blurred vision, or drooping eyelids. Slurred speech and dry mouth can follow along with general muscle weakness and difficulty swallowing. Botulism can quickly progress to respiratory failure.

Poisoning from botulism toxins through prison hooch can happen in a few hours or take up to 10 days to appear. A medical evaluation of symptoms is necessary to rule out other possible causes of progressing paralysis. Information about the potential of drinking homemade alcohol is important for a quick diagnosis and response. Question the patient and housing officers in a suspicious situation.

So, if home-brewing is a popular hobby at your facility, be particularly alert for signs of botulism poisoning among those who make and partake of this beverage. It may seem like a harmless way to keep the prisoners peaceful and preoccupied – but it also has potential to brew up some trouble.

Do inmates in your facility create their own drinking alcohol? Share your experiences in the comments section of this post.

Some material for this post was originally published for my health care column over at CorrectionsOne.Com.

During a jail intake for a homeless man brought in for vagrancy, a nurse sees some tiny insects flying about his clothing and he is scratching at them as she interviews him. She is concerned that an infestation may result and initiates a protocol for lice which involves shampooing and showering with the insecticide permethrin and a special laundering process for all clothing. Was this the right action? How do we do lice identification?

Correctional nurses need to be aware of various infestations as a high percentage of inmates in some locales are prone to head, body, and pubic lice. Once these little hitchhikers enter a facility they can spread by direct physical contact or through sharing of personal items like clothing, bedding, or towels. Was this patient infected with lice? Let’s look at some information about these little critters.

Do lice fly?

Lice remain on a person’s hair or clothing and wander to the skin to blood feed once or more often each day. They have tiny straw-like mouthparts – similar to those of mosquitoes – that they use to suck blood from skin capillaries. They’re unable to burrow into the skin. Lice never develop wings, so they cannot fly. They’re also incapable of jumping. So, this patient did not have lice.

Lice cause itching

Lice may cause an allergic reaction that can cause itching. For head lice, the itching tends to be mild and temporary. Body lice tend to cause far more itching, and even make the infested person feel ‘lousy’. Public lice tend to cause much itching in the affected area. This patient’s itching may be caused by the insect in question but further investigation is needed.

Lice are not very common

Lice are not nearly as prevalent as is generally believed, and other creatures and objects on a person are frequently mistaken for lice. Other insects include fleas, ticks, mites and bedbugs. None of these insects have wings, though. The homeless man in our case may merely have gnats or fruit flies about his person.

Lice are relatively tiny – as small as a poppy seed and as large as a sesame seed. A screener must have good eyesight, be close enough to see the creature, use a magnifying lens, and some expertise to identify lice; distinguishing them from other insects. In fact, other kinds of insects and even bits of debris are frequently mistaken to be lice. As in this case, misdiagnosis and unnecessary treatment can be frequent.

When in doubt – don’t treat

Treating everyone who enters a facility is not a good idea; nor is it cost effective. Treatment focused just on those infested is consistent with sound medical practice. It can also dramatically save time and precious funds; while reducing the risk of lawsuit. The standard medications used in prisons for delousing contain the insecticides permethrin and pyrethrins. These have become less effective as resistance is becoming widespread.

When positive lice identification is confirmed, treatment can be ordered as follows:

Head lice can be treated with one or two 10-minute applications of a pediculicide.

Body lice usually require no treatment to the person. Instead, a person with body lice should bathe and change into prison-issued clothing. The infested clothing should be disinsected by proper laundering, or disposed of. If body lice are detected on the body hairs of a person, a full-body treatment with a pediculicide is needed.

Pubic lice would necessitate treatment to the affected area only.

Ongoing prevention measures for lice include frequent (at least weekly) laundering of clothing and linens, and early recognition and treatment of genuine infestations. The Federal Bureau of Prisons Lice and Scabies Protocol of March 2011 recommends the following actions:

Be sure laundry temperatures are set to at least 130 degrees Fahrenheit to kill lice and their eggs on linens and clothing. Use a hot cycle for drying, as well.

Educate inmates about lice and how to get treatment if they observe lice. The FBOP Protocol includes inmate education handouts that might be helpful.

Inmates should not be transferred to other facilities until 24 hours after initiation of treatment. If moved before the 2nd treatment application (7 days), communication and continuation of treatment should be provided.

How are you managing lice, bedbugs, fleas, and ticks in your facility? Share your thoughts in the comments section of this post.

What exciting thing can be said about washing your hands? Even before becoming nurses, we heard this admonishment as youngsters in households across the fruited plain. Our Infection Control 101 lecture started with: Hand washing is the single most important infection control principle we have.

Infection is rampant in most correctional facilities. Our work settings were created for purposes other than healthcare and hold a population with known propensity for a variety of infectious conditions.

Yet, with all this knowledge and all this evidence before us, handwashing frequency is abysmally below standard requirement. I couldn’t find a study of handwashing in correctional settings, but a multihospital study cited by the CDC found only 36-59% of health care workers washing their hands where and when they should.

Nurse leaders from the Mayo clinic suggest that what we really need is not more knowledge but a culture change and environmental accommodations to improve hand washing frequency. In an article in the November, 2011 issue of Nursing2011, authors Johnson, Kachler, and SIska offer the following interventions to improve hand washing:

• Many areas in which clinical care is provided lack hand washing stations. Our facilities were not designed for health care practices.

• Soap and soap dispensers are valuable commodities and may be stolen by inmates

• Alcohol based hand washes burn with a clear flame and may raise concerns with custody staff.

An additional peculiarity of the correctional setting is our patient population’s propensity to take advantage of available resource for their benefit. To wit, inmates have been known to drink alcohol-based hand sanitizer. A recent event landed 4 inmates in the emergency room in Shelby County, AL. []. Although the CDC has not officially supported alcohol-free hand sanitizers, they are growing in popularity in school and correctional settings.

Are you using alcohol-free hand sanitizers? How are you making it easier to “Wash Your Hands!” in your clinical setting? Share your experiences in the comments section.

The Centers for Disease Control and Prevention (CDC) announced recommendations for a new treatment option for latent tuberculosis infection (LTBI) this past week. These recommendations are welcome news for correctional nurses challenged with managing LTBI treatment for their inmate population. Correctional nurses are in contact with a significant portion of the more than 11 million people in the US who are infected with the TB bacterium (4% of the population). Reports clock the incarcerated TB infection rate in US prisons at least 4 times higher. This rate is escalated further in under-developed countries. Improving behind-bars treatment of LTBI can significantly improve public health, in addition to the immediate benefit of decreasing infection transmission to inmates and corrections staff.

The current medication regimen for LTBI treatment is onerous, especially in secure settings. Treatments can last for 9 months and require daily doses of one or more mediations. The serious nature of tuberculosis makes this treatment most often given by direct observation, requiring the patient to be transported to the medical unit daily and observed taking the medication. The new guidelines still require DOT administration, but now the medication is only needed once weekly for 12 weeks for most patients with LTBI. This is a much more efficient regimen for the correctional setting.

Monthly clinical appointments for side effects and physical assessment

Patients Inappropriate for this Regimen

HIV-infected patients receiving antiretroviral treatment

Pregnant women

Patient with LTBI and presumed INH or RIF resistant

Children under 2 years

The CDC is currently collaborating with the Infectious Diseases Society of America and the American Thoracic Society to update their guidelines to include these recommendations. In addition, it is likely that the Federal Bureau of Prisons (FBOP) will include these significant changes in the next update of their January, 2010 Clinical Practice Guidelines.

2012 will be a good year to re-evaluate and revamp your TB clinical processes. How will these new guidelines change your practice as a correctional nurse?

Janice B Hill, RN, MPH, is a correctional nurse leader with nearly 3 decades of experience with the Pinellas County Sheriff’s Office in Largo, FL. She is an active nurse educator frequently presenting on juvenile standards for the National Commission on Correctional Health Care. She was instrumental in the development of Florida’s Model Jail Standards Medical Inspector’s Course. In addition, she is on faculty with the Florida Department of Health Bureau of Tuberculosis & Refuge Health and a Southeastern Public Safety Institute Instructor on Bloodborne Pathogens & other Communicable Diseases. In this episode she talks to Lorry about the state of the corrections system regarding Tuberculosis (TB).

New York State is considering increased oversight of HIV inmate care. This article had me considering the many issues and barriers to providing care for inmates with HIV. To be sure, healthcare providers have education, drug protocols and clinical practice guidelines specific for the correctional environment. Many of the medication regimens have been standardized and commonly available through prison pharmacy distributors. However, several elements of the operation of correctional facilities and the patients themselves mitigate against consistent care.

HIV is Now a Chronic Condition

Due to advances in treatment and pharmacologics, HIV is now considered a chronic condition. This can result in less attention to the details – not good for long-term outcomes. Many prison medical units now place HIV inmates into an Infectious Diseases Chronic Care Clinic. This is a good practice, as is regularly scheduled visits with ID specialists. The advent of televideo medicine allows for this specialty care practice without the burden of specialist access beyond the security perimeter.

HIV Treatment Requires a Well Educated Patient

The complexities of the treatment plan and medication regimen can overwhelm the most educated of individuals. The average inmate is undereducated and undermotivated toward long-term health, although there are always exceptions to this generality. Information about their condition and directions for any actions on their part need to be clear, simple and repeated often. This information can be mixed with social myths and misconceptions. An open and honest communication channel allows these myths to emerge and be dispelled.

DOT or KOP Medications – Decisions, Decisions

The two options for medication administration in corrections are DOT (Direct Observation Therapy) which requires the inmate to come to a pill line and receive a single dose of medication where it can be observed to be taken, or KOP (Keep on Person) which allows the inmate to self-medicate, having been given a 30 day supply of the prescribed medication.

DOT is inconvenient for the inmate but assures more consistent treatment. KOP allows inmate independence and self-care but requires a highly motivated and diligent patient. Both are used for HIV management depending on the philosophy of medical and correctional leadership.

Inmates Don’t Stay in One Place

I know this may seem hard to believe – it was for me – but inmates are not always that easy to find. Just when they are settled into a routine at one of the state prisons, there is a reason for transfer. Security may need to transfer an inmate related to classification, time remaining in the sentence or due to altercations, gang activity, or attempted collusion. In any case, the inmate is moved to another facility. Communication of medical condition or treatment plan can be missed since a medical condition is not a primary consideration, but secondary to the security issue warranting the move.

For all these reasons, and some I probably missed, HIV inmate care will remain a challenge. It requires a well-running system to overcome the inherent barriers to care in a security environment. Many medical units find success through the designation of a nurse who provides case management for the HIV inmates in the facility. However, all staff members, from those working sick call to those working the med pass line, must understand their role in the HIV treatment plan.

What are your thoughts on HIV inmate care? I look forward to your comments.

News that there are big issues with MRSA (methicillin-resistant Staphylococcus aureus) in some Illinois prisons got me thinking about how observant correctional nurses can have a great impact on reducing the incidence and spread of this deadly infection in inmate community, thereby protecting custody staff, as well. I am not familiar with the healthcare staffing patterns in IL Prisons, however, many facilities have a designated infection control (IC) nurse who focuses on prevention, containment and treatment of infections in the inmate community. Here are some of the key activities of an infection control nurse in corrections.

Education to Prevent Outbreaks

One of the main ways infection outbreaks are prevented is through continuous education of the inmates and custody staff about methods to decrease the spread of infection (Frequent Handwashing!!!). Inmate workers such as porters, kitchen help, and laundry workers need special education in methods to decrease infection spread. The generally low literacy levels of the inmate population require simple and practical instruction methods.

Environmental Scanning

IC nurses regularly round throughout the facility specifically checking for any conditions that might indicate an infection issue. From the temperature of the water in the laundry area to the location of raw foods in the kitchen, the nurse is looking for opportunities to prevent disease spread. Shower stall mold, empty soap dispensers and even leaks resulting in stagnant water are areas of concern. Custody staff are less likely to be attuned to the health implications of these issues. An alert nurse, working in conjunction with custody peers, can improve health conditions.

Inmate Assessment and Early Treatment

IC nurses focus on intake assessments which determine any potential infections which might be brought into the inmate community by new arrivals. Evaluations for TB, skin infections, and H1N1 or other flu symptoms take place at intake. Those with high potential for these conditions are isolated from the general population until definitive diagnosis can take place. These nurses are also often involved in the ongoing treatment of chronic infections such as HIV and hepatitis, by managing the Infectious Diseases clinics with the ID physician specialist.

Reporting and Responding

Most states have health departments which manage the public health and require reporting of any potential outbreak or pandemic situations. An IC nurse can be the key point person with the health department and initiate immediate action in the event of a potential outbreak. It appears that there was lack of communication with the health department in the IL situation cited above. Immediate response to a potential outbreak through containment and treatment can prevent further spread.

How do you keep the spread of infection under control? Share your tips in the comments section of this post.